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Neuropharmacology > Drugs used in migraine > Flashcards

Drugs used in migraine Flashcards

0
Q

what other symptoms are sometimes reported with migraines?

A

muscle pains
cognitive disruptions
autonomic symptoms - relatively rare

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1
Q

what is a migraine ?

A

headache accompanied by nausea, vomiting, photophobia and phonophobia
headache: idiopathic, paroxysmal, recurring, moderate to severe attacks, unilateral, throbbing, exacerbated by physical activity

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2
Q

what do most people have to do if they are suffering from a migraine ?

A

most people have to go and lie down until it passes, often in a dark and silent room

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3
Q

what can induce the onset of a migraine ?

A

often the onset is unclear but sometimes stress can induce them

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4
Q

how many people are affected by migraines ?

A

10-15% of worlds adult population

it is the 19th most common debilitating condition according to WHO

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5
Q

which gender suffers more from migraines ?

A

18% females and 6% males

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6
Q

when do migraines usually start ?

A

they begin around puberty and this increases to peak around 40s and the disappears

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7
Q

what are the 2 types of migraine?

A 
classical= 20% pain with aura
common= 80% pain without aura
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8
Q

what is aura ?

A

it is a focal neurological symptom
for diagnosis:
2 attacks with aura symptoms
3 of the following - transient, develop over 4+ minutes, aura lasts

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9
Q

what is 99% of aura made up of ?

A

visual disturbances

  • zig zag lines
  • shimmering lights
  • spreading to whole field of vision
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10
Q

what are the other disturbances caused by aura ?

A

SENSORY DISTURBANCES- numbness, spreading numbness that starts at the fingers and spreads to arms and then shoulder
APHASIC- difficulty speaking
BASILAR- loss of balance, double vision and fainting- this is in extreme cases
alternating body sites are affected with different attacks

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11
Q

what re the 5 distinct stages of migraines?

A

prodromal (30-40%)- awareness that you are likely to develop a migraine
aura (20%)- this is only present in classical migraines
headache- moderate to severe
resolution
postdromal- you dont feel 100% still you can sometimes feel nauseous

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12
Q

how long can attacks last for ?

A

last between 4-72 hours

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13
Q

what is the average number of attacks per year which migraine sufferers suffer from ?

A

12

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14
Q

what are the percentage of sufferers which have a family member that also suffers from them ?

A

80%

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15
Q

what is a thunderclap migraine?

A

this is when a headache starts all of a sudden

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16
Q

what are the causes of familial hemiplegic migraine ?

A

P/Q calcium channel chromosome 19- this accounts for about 50% of cases- it affects ion channels or proteins involved in maintaining ionic bases
Na+/K+ pump - chromosome 1

this form is relatively rare

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17
Q

what are the 2 main theories for sporadic migraines ?

A

vascular theory

neurovascular theory

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18
Q

what is the vascular theory ?

A

traditional theory
states that auras are caused by vasoconstriction of cerebral blood vessels followed by vasodilation which causes the headache- thought that this causes the visual and cognitive disturbances

19
Q

why is the vascular theory too simple ?

A

most patients dont experience aura therefore it doesnt explain what happens in the patients not suffering from aura
doesnt explain the premonitory features- the prodromal phase
recent blood flow studies do not support vascular theory because it appears that constriction is not followed by dilation

20
Q

what is the neurovascular theory ?

A

dilation of blood vessels and pain is triggered by neural rather than vascular signals

serotonin, nitric oxide, CGRP, substance P are all thought to be involved- serotonin and substance P are involved in pain and inflammation

in some patients cortical spreading depression is involved- ongoing reduction in nervous activity that spreads from 1 region of the brain to the next

21
Q

what are 2 methods of treatment ?

A

prophylaxis - ongoing treatment to prevent attacks

acute attacks- take treatment when you start to have an attack

22
Q

what are some simple analgesics used as acute treatment of migraines and what are the side effects ?

A

aspirin, ibuprofen, diclofenac and paracetamol - these are the most common ways to deal with migraines

side effects- GIT discomfort (due to inhibition of prostaglandin production), peptic ulceration and GIT bleeding

23
Q

what compound analgesics/antiemetics are used for acute treatment of migraines ?

A
  • gastric stasis is reduction in gastric contractions which will reduce the ability to absorb drugs - this occurs in migraines
    antiemetics are used to reduce nausea to also improve drug absorption
  • metaclopramide (D2 antagonist)/aspirin
  • metaclopramie/paracetamol
  • domperidone/paracetamol
  • lysine/aspirin/metaclopramide- the lysine increases aspirin absorption
24
Q

what is ergotamine ?

A

acute treatment for migraines

  • vasoconstrictor of blood vessels
  • serotonin and dopamine receptor agonist
  • used for 50 years but no longer really used due to its adverse effects
25
Q

what are the adverse effects of ergotamine ?

A

nausea, vomiting, abdominal pain, muscular cramps
overuse headache- body will adapt to ergotamine so you have to take more and more to overcome the headache
peripheral vasospasm
cold extremities, gangrene - as blood supply to extremities gets cut off
high first pass metabolism

26
Q

what are the contraindications associated with ergotamine?

A

pregnancy, CHD, peripheral vascular disease

27
Q

what are triptans ?

A

serotonin 1B/D agonists such as sumatriptan
highly specific for receptors in cranial blood vessels therefore very few peripheral side effects
cause vasoconstriction
activates serotonin receptors in trigeminal nuclei of brainstem- some of the pain associated with migraines appears to be caused by these nuclei
inhibits dural neurogenic inflammation
sumatriptan is effective in 60% of patients

28
Q

what are the side effects associated with triptans?

A

they are often frequent, and short lived
tingling/heat in head, neck, chest and limbs

other side effects of sumatriptan
- chest related symptoms- 40% of patient, pressure in chest and arms, shortness of breath, mimic angina
- nausea
- dizziness,
- flushing
- fatigue
some of these effects can be avoided by taken it as a nasal spray

29
Q

what are the contraindications associated with sumatriptan ?

A 
angina/mi
uncontrolled hypertension 
pregnancy/lactation 
children and >65 
also drug interactions with SSRIs, MAOIs and lithium
30
Q

what does it mean by triptan wars ?

A

the triptans were a major breakthrough and therefore many variations of them were produced

  • enable less headache recurrence
  • faster acting
  • it meant that if one was not effective another one could be tried
31
Q

what are examples of other triptans than sumatriptan ?

A 
naratriptan- most common because it has less interactions, fewer side effects
zolmitriptan 
rizatriptan
almotriptan
eletriptan
frovatriptan
32
Q

when is prophylactic treatment used for migraines ?

A

2-4 attacks per month

interfering with patients lifestyle

33
Q

why do patients need to be fully informed when taking medication propylactically ?

A

daily medication for potentially 30 years
may have unpleasant side effects
also have to allow it time to work- 2 months

34
Q

how much does prophylactic treatment ususally reduce migraines?

A

usually by about 50% but it may just be a short term solution

35
Q

what beta blockers can be used and prophylactic treatment and what are their effects ?

A

propranolol, metaprolol, timolol and nadolol
propranolol causes more than an 50% reducton in migraine attacks in 35-60% of patients
has no effect on reducing severity of duration of attacks

36
Q

what are the side effects of beta blockers ?

A 
drowsiness
fatigue, lethargy
sleep disorders, nightmares
depression 
memory disturbances 
hallucinations 
bronchoconstriction
cardiac failure 
cold extremities 
hypotension 
exacerbation of heart failure 
renal failure
37
Q

what are the contraindications associated with beta blockers ?

A

asthma and hypertensio

38
Q

what anticonvulsants are used as prophylactic treatment and what do they do ?

A

topiramate and sodium valporate
- only topiramate is licensed in UK
block voltage gated calcium cahnnels, increase GABA action at GABAa receptors and AMPA/KA antagonists

39
Q

what are the side effects of topiramate ?

A 
paraesthesia
fatigue
anorexia
nausea
taste disturbance 
diarrhoea
40
Q

what are the side effects of sodium valporate ?

A 
mild to moderate nausea 
vomiting 
gastrointestinal distrss 
infection 
alopecia
tremor 
asthenia 
dizziness 
somnolence
41
Q

what tricyclic antidepressants are used as prophylactic treatment ?

A

amitriptyline
not licensed in UK
need much lower doses compared to depression treatment

42
Q

what are the side effects of amitriptyline ?

A 
sedation
drowsiness
dry mouth 
weight gain
constipation 
mania
dizziness 
tachycardia 
blurred vision 
tremor
confusion 
arterial hypotension 
urinary retention 
akathesia
43
Q

what serotonin antagonists are used inn prophylactic treatment ?

A 
methysergide and pizotifen 
- have antihistamine and sertonin antagonistic effects 
- some have anticholinergic effects 
block serotonin 1, 2a and 2c 
2nd line of medication
44
Q

what are the side effects of pizotifen ?

A 
increased appetite- weight gain 
drowsiness 
antimuscarinic activity- dry mouth 
constipation
blurred vision
45
Q

what are the contrainidcations of pizotifen ?

A 
pregnancy 
breast feeding 
glaucoma 
urinary retention 
renal impairment
46
Q

what are the side effects of methysergide?

A 
rarely used now - only in hospitals 
very dangerous side effects
- retroperitoneal fibrosis 
- fibrosis of heart valves 
- behavioural disturbances 
- arterial spasm
can only be taken for 4 months before you have to have a month off

Neuropharmacology (15 decks)

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